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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 12/05/2024
Date Signed: 12/05/2024 10:33:05 PM

Document Has Been Signed on 12/05/2024 10:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA MANORFACILITY NUMBER:
392700769
ADMINISTRATOR/
DIRECTOR:		VINCELET, CRAIGFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14CENSUS: 12DATE:
12/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Momo DTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to conduct a case management for follow-up on the fire marshal re-inspection. LPA met with Momo and explained the purpose of today's visit.

Based on information received to the department a re-inspection will be conducted on or after 12/2/2024. If violations were not corrected upon re-inspection, a $561.00 fee will be applied for each additional re-inspection. This information was provided to the facility on 11/18/2024 after a re-inspection on 11/14/2024.

The department is requesting a copy of the re-inspection from most recent fire marshal re-inspection on or after 12/2/2024. Please provide this information by close business on 12/5/2024.

At this time the department does not have the information from the re-inspection and will return at a later date to follow-up on the requested information.

Exit interview conducted and the report given to the acting Administrator Momo D.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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